It’s a bumpy start for prior authorizations

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Friday, March 10, 2017

WASHINGTON – CGS and Noridian have begun accepting prior authorization requests for K0856 and K0861, but complex rehab providers say they still don’t have all the information they need to comply with the program.

The contractors on March 6 began accepting requests for dates of delivery on or after March 20.

“We’re as prepared as we can be, with all the unanswered questions,” said Doug Westerdahl, president and CEO of Rochester, N.Y.-based Monroe Wheelchair, who, because of the uncertainty, planned to push out the door as many wheelchairs as possible before March 20.

CMS is phasing in prior authorizations for the two codes, with this first phase applying to Illinois, West Virginia, Missouri and New York. A national rollout is slated for July 17.

Stakeholders aren’t pleased that CMS has moved forward with prior authorizations despite cancelling a Special Open Door Forum on the topic in January. The agency also included it as an agenda item for a general forum in February and dropped it at the last minute. It finally scheduled another Special Open Door Forum on March 9 for March 16th.

“We’ve gotten no official response on why it was cancelled and taken off the agenda,” said Don Clayback, executive director of NCART. “We understand that there are changes going on at CMS, but our position is, this is ridiculous.”

Stakeholders pointed out it wasn’t until the last minute that they had access to an operational guide, a document that paved the way for a smooth transition when CMS began requesting PAs for standard power wheelchairs as part of a demonstration project that’s now running in 19 states.

“That’s the one document that has been extremely important for providers who are currently doing the demo,” said Seth Johnson, vice president of government affairs for Pride Mobility Products. “That really has the necessary information that providers need to implement this and educate their employees.”

Additionally, stakeholders would like further guidance on, among other things, why the prior authorizations, unlike the advance determination of Medicare coverage process currently being used by many providers, only cover the base and not accessories.

“That’s a vague area that could get a little scary,” said Chuck Spiedel, the rehab manager for Springfield, Ill.-based Personal Mobility, who says he’s now sending documentation to the quality review team a second time to make sure it meets all the necessary criteria. “In my opinion, they shouldn’t be doing that. It’s a package of complex equipment.”

While CMS’s implementation hasn’t been seamless, stakeholders stand by the essence of prior authorizations.

“The demo has worked really well for us,” Westerdahl said. “So going into this, we’ve had a positive approach to it.